Thorax

MUDr. Veronika Němcová, CSc.

 Thorax
• Borders, lines, borders of lungs and pleura, heart projection,
auscultation
• Topography of the wall of thorax, intercostal spaces – chest
drainage, surgical approaches – sternotomy, thoracotomy
• Diaphragm – structures, nerve supplying, hernias
• Presternal region – sternal puncture
• Regio pectoralis, breast lymph nodes
• Clavipectoral triangle, subclavian puncture
• Pleural cavity, parietal pleura, recesses, cupula pleurae,
scalenovertebral triangle, pneumothorax
• Lungs – segments, impressions,pulmonary hilum, lymph nodes
• Superior mediastinum, crossection - schema, retrosternal
goitre, thymoma, superior vena cava syndrome - cavo-caval
anastomoses
• Inferior mediastinum (anterior, middle, posterior),
transoesophageal ECHO, oesophageal varices– porto-caval
anastomoses
Shapes of the thorax

Emphysema Pectus excavatum

 Muscles of the thorax

m.pectoralis
major

m.serratus
anterior

m.latissimus
dorsi
 m.trapezius

m.latissimus
dorsi
Long thoracic nerve palsy

scapula alata
(winged scapula)
Mamma
Breast - lymph nodes

Supraclavicular l.n.
Apical axillary l.n. Parasternal l.n.

Central axillary l.n.

Lateral axillary l.n.

Pectoral axillary l.n.

(Sorgius lymph node)
 Bordes of the lungs and pleura

area thymica

II

IV

VI

VII
VIII IX X

Lower borders of the parietal pleura

area pericardiaca are „+1 rib“
Pleura parietalis et
pleura visceralis

cupula
pneumothorax
pleurae
(5cm above
the thoracis
inlet)
pars costalis

pars mediastinalis

pars diaphragmatica

recessus
costodiaphragmaticus
 parasternal anterior axillary paravertebral line

Section through
the intercostal
space in

1-f.thoracica spf.
2- fascia endothoracica
3-pleura parietalis
4-membrana intercostalis ext.
5-m.intercostalis int
6-m.intercostalis ext
7-m.intercostalis intimus
8-membrana intercostalis int
9-m.transversus thoracis

VANA
Chest drainage – posterior axillary line above the level of the inferior
angle of scapule (Th7)

anterior axillary line

above
the rib

costodiaphragmatic !diaphragm, liver, spleen

recess ! lungs
! long thoracic nerve, lateral thoracic vessels
! intercostal nerv and vessels
Thorax - anterior wall (posterior aspect)
vessels
Median sternotomy
approach to thymus,
pericardium,
heart and roots of great
vessels,
and anterior mediastinum CT 14 days after sternotomy for bypass grafting
post surgery
wire migration
-sign of mediastinitis
3 weeks after sternotomy

wound dehiscention
• sternal puncture is a rapid and safe
method to ensure the diagnosis of post-
sternotomy mediastinitis
 Thorax – posterior wall
vessels and nerves
Ao
V.intercostalis suprema

V.azygos

Tr.sympaticus

Ductus thoracicus

Nn.splanchnici
 Thorax –inferior wall -diaphragm
4. intercostal space 5. intercostal space
Central tendon

lumbocostal triangle of
Bochdalek
 Diaphragm –inferior aspect Sternal part

Central tendon

Inferior v.cava Oesophagus

+frenic nerve +vagus
nerves

Azygos vein
+ splanchnic
nerves

Costal part Lumbocostal

triangle
(Bochdaleki)

Lumbar part Hemiazygos vein

sympathetic + splanchnic
quadratus psoas aorta + trunc nerves
lumborum major thoracic duct
Mediastinum oesophagus spatium retroviscerale
spatium paraviscerale
spatium previscerale

Superius
angulus sterni
P A
n. frenicus
Inferius M

aorta
diaphragma

abdominal cavity
Mediastinum superius
(thoracic inlet) Layers: sternum
rest of the thymus
veins
nerves
arteries
trachea
oesophagus
lungs (laterally)
 Superior mediastinum v.brachiocephalica dx
Schema of the crossection

vasa thoracica int.

• sternum v.brachiocephalica sin

• rest of the thymus n. frenicus n. frenicus

a.carotis comm sin
• vrstva žil tr. brachiocephalicus n.vagus sin
• nerves n.vagus dx a. subclavia sin
• arteries n.laryngeus
reccurens sin
• trachea
ductus thoracicus
• oesophagus
• pleuras Th3
tr. sympathicus

pleura
tr. sympathicus visceralis

pleura
parietalis
Repetition

Th3
 Superior vena cava syndrome

v.jugularis
edema of the
externa face, neck and
upper chest,

distension of
axillary,
subclavian and
jugular veins v.brachiocephalica dx
(compression)

v.cava superior

v.thoracica lat.

v.thoracoepigastrica v.cava inferior

A 75-year-old man smoker, stage IV
non–small-cell carcinoma of the lung
-progressive cough, hoarseness, and
swelling of the face and arms.
- On examination: plethoric, with a ruddy
complexion, suffusion, pitting edema of the
face and upper torso, and prominent
spidery telangiectasia on his face and
chest (Panel A). The jugular veins were
nonpulsatile and distended.
- Contrast-enhanced CT: markedly
compressed superior vena cava (SVC)
- venogram: (Panel B) severe compression
of both the right and left subclavian veins
(RSV and LSV), a thrombus in the left
subclavian vein and multiple venous
collaterals (arrowheads).
-After stent placement, extending from
the left subclavian vein into the superior
vena cava, the patient felt better within a
day, and was back to baseline at 27 days
(Panel C), the venogram (Panel D)
-14 months after the procedure and
chemotherapy, remains free of symptoms
resulting from the obstruction of SVC.
 Cavo-caval anastomoses
thoracoepigastric vein - superficial epigastric vein

superior epigastric vein – inferior epigastric vein

lumbal veins – azygos and hemiazygos veins

Subclavian Vein Cannulation
Retrosternal goitre
x-ray picture
Reccurent laryngeal
nerves
Young woman with dysphony
 left reccurent laryngeal nerve palsy

Ortners syndrome is a rare cardiovocal syndrome and refers to reccurent

laryngeal nerve palsy from cardiovascular disease (mitral stenosis, pulmonary
hypertension)

pulmonary artery dilatation

Posterior
mediastinum

n.vagus sin

v. azygos

ductus thoracicus
truncus sympathicus

n.splanchnicus major

oesophagus
 Mediastinum right veiw

n.vagus

n.frenicus

eparterial
ductus thoracicus bronchus

n.splanchnicus major

n.splanchnicus minor
Mediastinum right view
 Mediastinum left veiw

n.vagus

hyparterial bronchus
n.laryngeus
reccurens sin.

n.frenicus
+ vasa pericardiacofrenica
Mediastinum
transverse section (Th6)

truncus pulmonalis
aorta ascendens
n. frenicus sin
n. frenicus dx
v.cava superior
nn.vagi
oesophagus
bronchus
bronchus principalis sin
principalis dx
v. azygos
ductus thoracicus aorta descendens
Th6
tr. sympathicus dx v. hemiazygos

tr. sympathicus sin

Mediastinum
transverse section (Th8)

n.frenicus sin

n.frenicus dx

vv. pulmonales
n.vagus sin

n.vagus dx
ductus thoracicus
oesophagus
v. azygos Th8
aorta descendens
tr. sympathicus dx
Lungs and the heart – anterior aspect 1-lobus sup. dx
2-fissura horizontalis
3-facies sternocostalis
4-facies diaphragmatica
5-sulcus interventricularis ant.
6-tr.brachiocephalicus
7-trachea
8-a.carotis communis sin
9-a.subclavia sin
Lungs – posterior aspect

1-lobus inf.dx
2-lobus inf.sin
3-aorta
4-jícen
5-trachea
Medial wall of
the right lung apex
sulcus a. subclaviae
sulcus v.cavae sup.
1.rib impression

sulcus v.azygos
a.pulmonalis dx bronchus principalis dx
mesopneumonium
sulcus v.azygos
vv.pulmonales sulcus oesophageus
impressio cardiaca

fissura horizontalis lig. pulmonale

basis
fissura obliqua
pulmonis
Medial wall of
the right lung
 Medial wall of apex
the left lung
sulcus a. subclaviae
fissura obliqua
sulcus
v.brachiocephalicae sin
1.rib impression
sulcus aorticus
a.pulmonalis sin
bronchus principalis sin vv.pulmonales sin
mesopneumonium

impressio cardiaca

lig. pulmonale
impressio
oesophagea

lingula pulmonis

basis pulmonis
Medial wall of
the left lung
 Lymph of the lungs truncus bronchomedistinalis
truncus tracheobronchialis
n.l.paratracheales dx n.l.paratracheales sin

n.l. tracheobronchiales sup sin

n.l. tracheobronchiales sup dx

n.l. tracheobronchiales inf

n.l.pulmonales

n.l.bronchopulmonales
perilobular (v hilu)

subpleural + peribronchial
 • Superior Mediastinal Nodes (1-4)
• 1. Highest Mediastinal: above the left
Regional lymph node classification for lung brachiocephalic vein.
• 2. Upper Paratracheal: above the aortic arch,
cancer staging adapted from the American but below the left brachiocephalic vein.
• 3. Pre-vascular or Pre-vertebral: these nodes
Thoracic Society mapping scheme are not adjacent to the trachea like the nodes
in station 2. They are either anterior to the
vessels (3A) or behind the esophagus, which is
prevertebral (3P).
• 4. Lower Paratracheal (including Azygos
Nodes): below upper margin of aortic arch
down to level of main bronchus.
•

• Aortic Nodes (5-6)

• 5. Subaortic (A-P window): nodes lateral to
ligamentum arteriosum. These nodes are not
located between the aorta and the pulmonary
trunk, but lateral to these vessels.
• 6. Para-aortic (ascending aorta or phrenic):
nodes lying anterior and lateral to the
ascending aorta and the aortic arch.
•

• Inferior Mediastinal Nodes (7-9)

• 7. Subcarinal.
• 8. Paraesophageal (below carina).
• 9. Pulmonary Ligament: nodes lying within
the pulmonary ligaments.
•

• Hilar, Interlobar, Lobar, Segmental and

Subsegmental Nodes (10-14)
• 10-14: these are located outside of the
mediastinum.
They are all N1-nodes.
Lymph nodes in the
superior mediastinum

4R, 3A
44-year-old HIV-positive man presents with progressive
dysphagia, epigastric pain, and post-prandial vomiting

Lymphoma of the esophagus

 Oesophagus- endoskopy

G-E junction, 2 cm above cardia

ora serrata, Z-line)
squamocolumnar junction

vein
squamous epithelium

Transverse ridging of the normal esophagus columnar epithelium

becoming evident during retching
 Main porto-caval
anastomoses

vv. oesophageae-vv.gastricae
! esophageal varices-bleeding

vv.paraumbilicales - caput Medusae

v.rectalis superior-v.rectalis media

hemorrhoids-bleeding
Thorax – x-ray picture
CT - adenocarcinoma, emphysema
CT – thymoma in the anterior mediastinum
CT – thymoma in
the anterior
mediastinum
CT – aspirated tooth filling in the left lower bronchus
CT- ganglioneuroma in the posterior
mediastinum
CT- ganglioneuroma in the posterior
mediastinum
???
Breast implants
 Sources
• Grim, Základy anatomie, 5.díl
• Petrovický et al., Anatomie II
• Elišková, Naňka, Přehled anatomie
• Schwarzenegger, Encyklopedie kulturistiky
• http://anatomy.med.umich.edu/atlas
• http://www.auntminnie.com
• http://www.radiologyassistant.nl
• http://jtcs.ctsnetjournals.org/cgi/content/full/125/3/611/FMTC03164002
• http://www.breastcancer.org/treatment/surgery/lymph_node_removal/lymph_nodes.jsp
• Mukesh Tripathi, MD, Mamta Tripathi, MBBS, Subclavian Vein Cannulation: An
Approach With Definite Landmarks
• An anatomic landmark to simplify subclavian vein cannulation: the "deltoid tuberosity".
von Goedecke A, Keller C, Moriggl B, Wenzel V, Bale R, Deibl M, Moser P, Lirk P.
Department of Anesthesiology and Critical Care Medicine, Medical University of
Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria. achim.von-goedecke@uibk.ac.at